15 April 2011 Impressions 5 - during The Pause: data analysis
So, the Health and Social Care Bill's journey is paused, but the papers and data keep on coming. A few to know about:
The Association of Public Health Observatories general practice profiles are live. These allow for comparative analysis of perfomance against a number of indicators including respiratory ones. You can select clusters to compare. See a snapshot here. This, and the Atlas of Variation start to really build on visual displays of information. See also our guides to how to use information and medicines information.
The Audit Commission published Reducing expenditure on low clinical value treatments on 14 April 201. It estimates that nationally a reduction in PCT spending of between £179m-£441m is achievable. It used the "Croydon List" of 34 low priority treatments to estimate spending over a five-year period 2005/6-2009/10 and to forecast what could have been saved.
The "Croydon List" has 5 categories of treatment
- Those considered to be relatively ineffective, eg a tonsillectomy.
- Those where more cost-effective alternatives are available, eg not performing a hysterectomy in cases of heavy menstrual bleeding.
- Those with a close benefit and risk balance in mild cases, eg wisdom teeth extraction.
- Potentially cosmetic procedures, eg orthodontics.
- Procedures cancelled after patient admitted for that procedure
They are procedure-based and none are respiratory but maybe the categories could be applied to respiratory? It's also difficult to believe that there's still scope to improve on these treatments as these have been on the "hit list" fo years. However, the general messages are pertinent (if unsurprising)
- Achievement of the reductions requires senior level leadership;
- Groups of PCTs working together can improve the consistency of messages to clinicians;
- Put effort into the data analysis and performance monitoring;
- Involve GPs and secondary care;
- Produce and engage in accessible communication with the public
- Use the latest clinical evidence
The Audit Commission supports the DH Right Care work to develop the required evidence base, which is seen as the main stumbling block. In the Audit Commission survey PCTs said they currently used these evidence-bases:
NICE, NHS Library, NHS Evidence, Clinical Knowledge Summaries, National Prescribing Centre, DH Evidence Based Commissioning, Turning Research into Practice, Map of Medicine , The NHS Atlas of Variation.
This begs the question how do we ensure that the best respiratory evidence is in all these places?
We'd also recommend from the Audit Commission their work on coding assurance, with a lot of examples of good practice.
Did you see the Editorial in the BMJ by David Halpin about case-finding and needing to work harder to find the missing people. He's also suggesting going where the people are (see Impressions 4) and also quotes the Finnish study (Impressions 2). Can't help thinking that we need to be smarter about working with occupational health and offering an exchange - delivering what the employees want, in addition to what we want to offer. Has anyone run a successful COPD case-finding programme with occupational health? Email [email protected] if you have!
Siân Williams
7 April 2011 - Impressions 4 Avoiding admissions again - three new reports suggesting we need to go to where the patients are
Calderon-Larranaga A et al Association of population and primary healthcare factors with hospital admission rates for chronic obstructive pulmonary disease in England: national cross-sectional study Thorax 2011;66:191-196 This shows, as Jones' commentary says that the "inverse care law is alive and well". The authors from Imperial and the Care Quality Commission integrated routinely collected data from over 8000 practices caring for over 53 million people in England. Mean annual COPD admission rates per 100 000 population varied from 124.7 to 646.5 for PCTs and 0.0 to 2175.2 for practices. Admissions were strongly associated with population deprivation at both levels. Registered and undiagnosed COPD prevalence, smoking prevalence and deprivation were risk factors for admission (p<0.001), while healthcare factors- influenza immunisation, patient-reported access to consultations within two days, and primary care staffing, were protective (p<0.05).
Another on the need to test effective case-finding comes from Nacul L. COPD in England: a comparison of expected, model-based prevalence and observed prevalence from general practice J Public Health (2010) by a team from Imperial, Cambridge and the East of England PHO. Both observed and expected prevalence of COPD varied widely between geographical areas. There was evidence of a north–south divide, with both observed and modelled prevalence higher in the north. The ratio of diagnosed to expected prevalence varied from 0.20 to 0.95, with a
mean of 0.52. Underdiagnosis was more pronounced in urban areas, and is particularly severe in London. Analysis suggests that primary care supply affects diagnosis. The team recommends the use of the APHO COPD prevalence model that contains estimates for GP practices’ registered populations,
Meanwhile, an evaluation by the Nuffield Trust Steventon et al. An evaluation of the impact of community-based interventions on hospital use: a case study of eight Partnership for Older People Projects (POPP) 2011 shows a disappointing impact on hospital admissions and recommends commissioners consider using "person-based risk-adjusted evaluation" to test whether preventive care interventions are effectively avoiding hospital admissions. When compared to matched control patients, they did not find evidence of a reduction in emergency hospital admissions associated with any of the POPP interventions studied. In some instances, there were more admissions in the intervention group than in the control group. One intervention reduced the number of bed-days, but overall they found that the interventions studied did not appear to be associated with a reduction in the use of acute hospitals. They offer one possible explanation- that the process of ‘case finding’ identified unmet need that necessitated hospital admission.
So, more dialogue needed on the best ways for case-finding, what we might expect to see happen to admissions as a result of case-finding, and the real need to focus on areas of deprivation and the factors that appear to make a difference.
Siân Williams
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31 March 2011 Impressions 3 THE STATE OF HEALTH AND SOCIAL CARE IN ENGLAND, CQC ANNUAL REPORT - HOSPITAL DISCHARGE
The Care Quality Commission (CQC) has just published (28 March 2011) its annual report on The state of health care and adult social care in England.
It finds encouraging signs and gives evidence that standards of health and social care are improving overall - which has been picked up by some of the media that has then questioned the need for so much change. Care was safer in 2009/10 than in previous years. There were fewer healthcare-associated infections and services had made improvements in protecting adults from abuse and neglect. However it claims unacceptable variation remains.
There are useful updates on the extent of progress towards personalisation in social care, and the impact of choice in terms of mixed provision of care particularly in home care, and care homes. Apart from a special report on stroke, there is no disease-specific information. However, it shows "mixed progress in avoiding unnecessary hospital admissions and ensuring effective hospital discharge, with much variation between councils. There was significant growth of intermediate care services, but the numbers of people over 75 who had repeated emergency admissions suggested a lack of effective community support. "
Hospital discharge still has considerable scope for improvement: From the patient survey data:
- 37% said they were not given written or printed information about what they should or should not do after leaving hospital
- 25% said they were not told whom to contact if they were worried about their condition
- 33% said that doctors and nurses did not give their family or someone close to them all the information they needed to care for them
- 18% said they were not given clear written or printed information about their medicines, and 45% said they were not told about possible side-effects
It will be interesting to see whether solutions such as the COPD discharge bundle start to address this.
The Department of Health’s guidance states that patients should receive copies of letters sent between clinicians. Although the majority of inpatients (53%) did not receive copies of letters sent between hospital doctors and their GPs, the proportion of those who did improved from 35% in 2005 to 47% in 2009. There had also been some improvement for outpatients – the percentage who said they had received some or all of these letters rose from 22% to 44%.
Councils are required to set eligibility criteria that determine who can receive their community care services, and to use a national framework to grade the level of need. This is one of the processes used to manage demand for services and control council expenditure on care. In 2009/10, three councils set their eligibility threshold for care-managed services at “critical” while 107 set their threshold at “substantial”. Only three councils were planning to raise their eligibility threshold in 2010/11, while one was expecting to lower its threshold from “substantial” to “moderate”. However, the number of people receiving publicly funded services in 2009/10 fell by nearly 5% against the previous year, according to (provisional) national statistics. It will be important to see how access to these services is maintained when local authorities implement their funding cuts during 2011/12.
Siân Williams
25 March 2011 Impressions 2 QUALITY AND PRODUCTIVITY IN PRIMARY CARE
There may be some opportunities in the new QOF indicators that respiratory networks may wish to discuss locally. As well as the continuation of stop smoking, asthma and COPD indicators, there are 96.5 points available out of a possible 1000 for new quality and productivity indicators that aim to ""secure more effective use of NHS resources, in particular through improvements in the quality of primary care that reduce hospital outpatient referrals, and emergency hospital admissions by providing care to patients through the use of alternative care pathways, and through more cost-efficient prescribing."
We need to understand more how this will be measured, but the negotiated position is that there are two indicators:
- reducing emergency hospital admissions associated with long term conditions where there is evidence that appropriate management of these conditions in primary care reduces emergency admissions;
- reducing inappropriate outpatient referrals
Practices will receive the full payments for these areas if, following internal and external practice reviews, they are implementing care pathways that are intended to have the effect of reducing unnecessary referrals and admissions.
So how might we ensure changes that benefit patients with COPD and asthma pathways are considered?
In terms of outpatient follow-ups see our work More for Less and also Delivering Respiratory Care Closer to Home
In terms of emergency admissions, see below.
Also, have a look at the new publication from 10 years of the Finnish programme on COPD: The 10-year COPD Programme in Finland: effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality
Meanwhile, I heard I heard DrJames Kingsland, DH national clinical commissioning network lead and President of the National Association of Primary Care speak this week at an internal meeting hosted by Glaxosmithkline. He has the challenge of finding 500 champions for GP commissioning. He is trying to get GPs to stop worrying about the financial and organisational implications, because form should follow function, and instead to start testing the potential for making commissioning more needs-led and also addressing the QIPP challenge by focusing decision-making on whether they should "make or buy" services to meet those needs. He had five challenges for English GPs which seem useful messages about integrated care that we could support:
- How are you taking on board the "no decision without me" principle and engaging patients in commissioning decisions to ensure : have you a process for this now there is funding to support it
- How are you benefiting from the collective experience of the multi-disciplinary primary care team, including the other contractors and community providers in assessing patient need?
- Are you having regular meetings with your local authority colleagues to discuss integration with social care and alignment with public health?
- The QIPP challenge will require more long term conditions to be managed outside hospital so have you begun a dialogue with clinicians in secondary care about how to downsize but not destabilise, and support high quality high technology hospital care?
- How do you plan to restore/increase the value of list-based practice and its opportunity to manage demand by making more and buying less (including better management of out of hours)?
His second main message was also one that we could support: where's the value, defined as outcomes divided by cost. Sir Muir Gray has got a useful blog about this, referring to Michael Porter's work on this.
To see an interview with James Kingsland, have a look at this with Roy Lilley.
Siân Williams
Programme Manager
8 March 2011 1st go! 1. AVOIDING HOSPITAL ADMISSIONS AND 2. TELEHEALTH
Two really good papers have come out recently. Remote Control - see below and, Avoiding hospital admissions. What does the research evidence say? Sarah Purdy, Kings Fund, December 2010 Go here to see the full paper including all the references.
Sarah Purdy - who's speaking at the IMPRESS conference on 24 May 2011 - has reviewed the research literature about avoiding hospital admission.
Here are the main findings in relation to respiratory care:
Demographic factors
People from lower socio-economic groups are at higher risk of avoidable emergency admissions.
Practices serving the most deprived populations have emergency admission rates that are around 60–90 per cent higher than those serving the least deprived populations (Blatchford et al 1999; Purdy et al 2010a).
This is well-illustrated in COPD. Also practices with higher recorded chronic disease burden have a higher rate of admissions.
Those who live in urban areas have higher rates of emergency hospital admission than those in rural areas; Eg the authors found a 16% higher rate of asthma admissions for urban patients compared with rural patients (Purdy et al 2010a). They also found those who live closer to A&E departments have higher rates of admission (for instance, a 12 per cent higher rate of admission for asthma), even after taking into account other risk factors, including living in an urban area (Purdy et al 2010a). The reasons are less clear.
Being from a minority ethnic group is associated with a higher risk of emergency admission. For example, in the UK, asthma admission rates for South Asian patients have been double those of white patients, and are also high for black patients (Gilthorpe et al 1998). Different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission among South Asian patients (Griffiths et al 2001).
Cold weather is associated with increased rates of admission for COPD exacerbations (Maheswaran et al 2005; Moran et al 2000; Marno 2006).
Risk prediction
There are several tools available to help identify people at high risk of future emergency admission, including computer database models and simple questionnaires. There is no clear advantage of using one tool over another. Purdy includes an appendix that describes five tools.
It is important to be clear which admissions are potentially avoidable and which interventions are likely to be effective. Clarity of disease coding is essential. IMPRESS recommends commissioners discuss with providers which diagnostic codes they class to be avoidable, what proportion of these admissions are avoidable, and how these admissions should be measured. In terms of tools, we offer:
Services
Primary care
In primary care, higher continuity of care with a GP is associated with lower risk of admission. There is mixed evidence about size of practice: small size/single handed may be associated with increased admissions for asthma but not COPD.
Integrating health and social care may be effective in reducing admissions.
Look out for our case study from North Tyneside, one of the national integrated care pilots
Integrating primary and secondary care can be effective in reducing admissions. One of the core principles of IMPRESS. See Curry and Ham 2010. This review concludes that the evidence is supportive of the concept of integration. The authors highlight the importance of integrating not just at the health system level, but also at the disease management and individual patient levels.
Use of specialists in the community
There is very little evidence to suggest that clinics provided by hospital specialists in primary care reduce hospitalisation rates when delivered in isolation (Gruen et al 2003). However, this systematic review found that specialist outreach, as part of more complex multifaceted interventions involving collaboration with primary care, education or other services, is associated with less use of inpatient services. See the IMPRESS guidance about integrated care consultants and referral letter.
Telemedicine seems to be effective for patients with heart failure, but there is little evidence that it is effective for other conditions.
We ask commissioners to pay particular attention to this, given our observation that a considerable number of telemedicine schemes are being introduced, at considerable expense without the evidence, and instead of interventions with good cost effectiveness data. It is worth waiting for the outcomes of the Whole Systems Demonstrator projects to see if they are cost effective, and if there are (modifiable) clinician behaviours that make them effective. However, we would recommend reading Remote Control This focuses on how digital or 'multi-channel' healthcare can have an impact on the fundamental relationships between patients and practitioners. Telephone, email and the internet can offer patients and carers choice and a rebalancing of power and control. However the tariff needs to encourage the provision of options - that email or phone consultations may be the patient's preferred option, but they won't happen if there's no suitable tariff.
Hospital at home produces similar outcomes to inpatient care, at a similar cost. Shepperd et al 2009a) Elderly patients with a medical event such as stroke or COPD, who are clinically stable and do not require diagnostic or specialist input, had slightly more subsequent admissions in the hospital at home group, but had greater levels of satisfaction, and their care at home was less expensive. Commissioners should therefore consider this.
Case management in the community and in hospital is not effective in reducing generic admissions.
We would like to see further evidence about the impact of specialist teams supporting generic workers.
Self management
There is evidence from systematic reviews that self-management seems to be effective in reducing unplanned admissions for patients with COPD and asthma. Self- management education for patients with COPD reduces the risk of at least one hospital admission by about 36 per cent compared with usual care (Effing et al 2007). This translates into a one-year number needed to treat (NNT) of 10 for patients with more severe disease (51 per cent risk of exacerbation), and 24 for those with milder disease (13 per cent risk of exacerbation). Self-management education was associated with a reduction in shortness of breath and an improved quality of life.
Education for adult patients with asthma attending A&E with an acute exacerbation significantly reduced admission to hospital by 50 per cent, but did not significantly reduce the risk of re-presentation at A&E during follow-up (Tapp et al 2007). A previous study also showed that a brief self-management programme during hospital admission reduced post-discharge morbidity and re-admission for adult asthma patients. The benefit of the programme may have been greater for patients admitted for the first time. It had a small but significant effect on medical management at discharge (use of medications in line with current guidelines) that may explain the benefits of this approach (Osman et al 2002). There is also evidence that asthma education aimed at children and carers who present at A&E with acute exacerbations can result in lower risk of A&E attendance and admission (Boyd et al 2009). Following an educational intervention delivered to children, their parents, or both, there was a significantly reduced risk (21 per cent) of subsequent hospital admissions. However, there is a suggestion that the benefits of psycho- educational interventions may not be as evident in those patients with severe and difficult asthma (Smith et al 2005).
Not all studies of self-management demonstrate reduced hospital or A&E department use, and there is some debate over which ‘active ingredient’ in self-management is the most effective. One review of 15 studies measuring the impact of adult asthma self- management education on health care utilisation and costs found that eight studies demonstrated reduced hospital or emergency department use, while seven failed to demonstrate a reduction (Bodenheimer et al 2002). Six of the eight studies that did demonstrate a reduction included a self-management action plan, compared with three of the seven that did not, suggesting that a self-management action plan is a useful component.
Ways to support this in respiratory care include asthma action plans, and pulmonary rehabilitation.
Out of hours
A fivefold variation in out-of-hours admission rates has been observed between GPs working for the same out-of-hours service and caring for the same patient population, suggesting that clinician factors play an important part in determining admission rates (Rossdale et al 2007). Qualitative research in the same group of GPs suggests this may be due to lack of confidence, feelings of isolation, aversion to risk and lack of awareness of alternatives to admission (Calnan et al 2007) – all of which are modifiable factors.
Medication review
No positive evidence for medication reviews by pharmacists
Quality of primary care
The evidence for an association between higher quality of primary care (as measured by routine data) and reduced rates of admission is mixed. Lower rates of admission for asthma were found in practices whose prescribing patterns suggest better preventive care (Giuffrida et al 1999). However, the evidence is not conclusive. More recent research did not find any association between Quality and Outcomes Framework (QOF) scores and hospital admission for patients with asthma, COPD or coronary heart disease (Downing et al 2007; Bottle et al 2008). Provision of diabetes clinics in primary care was significantly associated with reduced admission rates for diabetes, but the provision of asthma clinics was not associated with a similar reduction in admissions (Saxena et al 2006). Conversely, a systematic review showed that high standards of diabetes care in primary care do not necessarily lead to reduced hospital admissions (Griffin and Kinmonth 2006).
Acute assessment units may reduce avoidable admissions, but the overall impact on number of admissions should be considered.
A systematic review of paediatric hospital-based acute assessment units also demonstrated that they are a safe, efficient and acceptable alternative to inpatient emergency admissions (Ogilvie 2005). One study showed that after the intervention, the proportion of children with asthma who were admitted fell from 31 to 24 per cent.
Early review by a senior clinician in the emergency department is effective. GPs working in the emergency department are probably effective in reducing admissions, but may not be cost-effective.
There is a lack of evidence on the effectiveness of combinations of interventions.
Re-admissions
Developing a personalised health care programme for people seen in medical outpatients and frequently admitted can reduce re-admissions. This should be tempered by an analysis of those people with COPD whose disease will inevitably cause frequent admissions, irrespective of any programme.
Structured discharge planning is effective in reducing future re-admissions.
The COPD discharge bundle approach is worth considering. It is being tested in NHS London as a CQUIN and as a project supported by the north London HIECs.
Meanwhile A systematic review of the effectiveness of nurse-led interventions pre- and post- discharge for COPD patients showed that brief (one-month) nurse-led interventions post-discharge did not reduce admission rates (Taylor et al 2005b). The evidence for longer (one-year) interventions is equivocal.
So - worth reading carefully, and debating locally. Come and listen to Sarah Purdy at the IMPRESS conference!
Siân Williams